Meet Growing Demand with These Medicare Advantage Billing Tips

In 2019, more than 64 million Medicare beneficiaries in the U.S. are covered by traditional Medicare, but more than 22 million Medicare beneficiaries (34%) have enrolled in Medicare Advantage plans (also known as MA, Medicare Part C, or Medicare replacement).

In the past decade, enrollment in Medicare Advantage plans has more than doubled. The Centers for Medicare and Medicaid (CMS) report that Medicare Advantage plans “continue to be popular, with enrollment projected to increase to an all-time high of 24.4 million beneficiaries in 2020.”

Graphic Source: Kaiser Family Foundation

Because Medicare Advantage enrollments continue to increase, patient benefits vary from plan to plan, and rules can change every year, it’s critical to refresh your Medicare Advantage billing knowledge base.

Here are a few Medicare Advantage stats, tips, challenges, and solutions to guide your eye care practice toward managing healthier cash flow.

Why Understanding Medicare Advantage Billing is Critical

Medicare Advantage plans are an “all in one” alternative to traditional Medicare plans that are offered through private insurance companies.

Medicare Advantage plan options include health maintenance organizations (HMO), preferred provider organizations (PPO), private fee-for-service (FFS) plans, special needs plans, and Medicare medical savings accounts (MSA) plans.

All Medicare Advantage plans are approved by Medicare and must follow CMS rules regarding coding, billing, submitting claims, and reimbursement.

How Medicare Advantage is Evolving in 2020

• “Beneficiaries will have more plan choices, with about 1,200 more Medicare Advantage plans operating in 2020 than in 2018.” – CMS.gov

• “Nationwide, 3,148 Medicare Advantage plans will be available for individual enrollment for the 2020 plan year—an increase of 414 plans since 2019.” – Kaiser Family Foundation

• UnitedHealthcare is expanding its Medicare Advantage “bundled payment program” to more than 30 states. – HealthPayer Intelligence

• “In 2019, “nearly two-thirds (62%) of all Medicare Advantage enrollees are in HMOs, and 31% are in local PPOs in 2019.” – Kaiser Family Foundation

• “The average Medicare beneficiary has access to 28 Medicare Advantage plans in 2020.” – Kaiser Family Foundation

To complicate things even more, depending on your state or even city, the number of Medicare patients enrolled in a Medicare Advantage plan can vary.

Graphic Source: Kaiser Family Foundation

Medicare Advantage Billing Guidelines to Follow

1. Don’t confuse Medicare Advantage plans with supplemental plans.

If a patient has a Medicare Advantage plan, do not bill traditional Medicare. Medicare Advantage plans are NOT supplemental plans, and they must cover all traditional Medicare services, including Part A (hospital insurance) and Part B (medical insurance) coverage. Most Medicare Advantage plans cover Part D coverage (prescription drugs).

2. Always verify vision benefits to avoid billing rejections and denials.

Many Medicare Advantage plans provide extra coverage for vision-related items or services, such as preventive and routine vision coverage, eyeglasses, and intraocular lenses (IOLs) related services.

Medicare Advantage benefits vary from plan to plan, bill different out-of-pocket fees, and have rules for how you get paid for your services. That’s why having eligibility and benefits verification is a critical first step in the intake process.

Medicare Advantage payers usually pay providers on a per member per month (PMPM), partial or full-capitation, or a percent-of-revenue basis.

PRO TIPS:

• Verify the insurance data is correct by confirming the insurance plan policy effective and term dates.

• Obtain prior authorization for specific services, if needed.

• Verify the patient’s out-of-pocket costs (co-payments, co-insurance, and deductibles).

3. Stay current with LCD and NCD guidelines.

Medicare Advantage plans follow Medicare guidelines, and providers must retain or have access to appropriate documentation if requested.

To ensure you are coding your eye care claims correctly, be diligent with CMS Local Coverage Determinations (LCD) and National Coverage Determinations (NCD).

Real-World Medicare Advantage Billing Challenges and Solutions

When Fast Pay Health billing consultants accepted the challenge of reducing the Medicare aging bucket for an Illinois-based optometry practice, they found most of the denied claims should have been billed to a Medicare Advantage plan and not Medicare.

Let’s look at the challenges, solutions, and outcomes Fast Pay Health put into action for this practice to reduce the aging days and improve cash flow.

Challenges:

• The practice consistently had more than $50,000 in outstanding Medicare claims in the 60+ day bucket.

• Billing staff was not performing eligibility and verification on most patients to determine if they were enrolled in traditional Medicare or a Medicare Advantage plan.

• Medicare claims submitted were denied (“covered by another payer”) since the patient was enrolled in a Medicare Advantage plan.

Solutions:

• Implemented a consistent eligibility and verification process for all patients.

• Verified that patient demographic information, date of service, insurance plan data, and policy effective and term dates were correct before submitting the claim, as well as verified co-pays for exam and materials for vision insurance plans.

• Refiled denied Medicare claims to the Medicare Advantage plan (if vision benefits are available) or filed a claim with a supplemental vision insurance plan.

Outcomes:

• Healthier cash flow

• Fewer denials

• More than 80% of refiled denied claims were paid

• Lower accounts receivable

• Happier providers and staff

Most major medical payers process claims in 5 to 7 business days—some even pay the same time every month or even every week. Accurate claim information is directly related to receiving reimbursements and avoiding billing rejections and denials.

Pay close attention to filing deadlines—each insurance carrier has its own guidelines. Sometimes you only have up to 30-120 days from the date of service to submit a claim, or it will be denied. If you can’t bill the patient or appeal to the insurance company, the appeal process is often cumbersome.

Consistent Eligibility and Benefits Verification is Critical

Researching rejected and denied claims is a time-consuming process. You and your staff can spend hours each week analyzing unpaid claims and EOBs to determine the necessary steps to correct and reprocess denied claims.

Don’t let inadequate insurance eligibility and benefits verification and avoiding denied claims create aging bucket chaos in your practice. The financial health of your eye care practice depends on higher efficiency and support to make your AR cleaner.

Complete, proactive optometry billing and revenue cycle management solutions are what we prescribe. Fast Pay Health is ready to help you get paid faster and grow your practice. Request a free practice analysis today.